Ensure the Most Current Form Is Submitted. Refer to EMACS Forms/Procedures Website s1

Ensure the most current form is submitted. Refer to EMACS Forms/Procedures website.

STALE DATED WARRANT

REQUEST

Must print in Black or Blue ink ONLY

Warrant Number

Issue Date

Warrant Amount

Stale Date

Reissue to Payee:

Employee ID

Rcd No.

Last Name, First Name

Mailing Address

City

State

Zip

Telephone

( )

Stale dated warrant must be attached, if available, otherwise you will be contacted for additional processing.

Employee Signature

Date

Payroll Specialist Name (Print & Sign)

Date

Department

Telephone

( )
Office Use Only

Warrant or Affidavit is attached

Send Affidavit to Payee address above, if needed

Please cancel and reissue

Address update, use above information

Special Instructions:

Authorized EMACS-Payroll Staff (Print & Sign):

Date:

/ /

Sign

For Accounts Payable Use Only
Affidavit Mailing Date: / Stop Payment Date:
Cancel Date: / Reissue Date:
Shred Date: / By: / , IAS
Review Date: / Keyed By: / , A/P

DISTRIBUTION: Original – EMACS-Payroll (0030)

Copy – Department

Rev. 05/19/10 (Stale Dated Warrant Request)